SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: This rule amendment updates the method for determining supplemental distributions to hospitals beginning with state fiscal year (SFY) 2008.
Citation of Existing Rules Affected by this Order: Amending WAC 388-550-5450.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.160, 74.09.500, and 70.168.040.
Adopted under notice filed as WSR 08-04-079 on February 4, 2008.
A final cost-benefit analysis is available by contacting Ayuni Wimpee, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1835, fax (360) 753-7315, e-mail firstname.lastname@example.org.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: March 31, 2008.
(2) Beginning with trauma services provided after June 30, 2003, the department makes supplemental distributions from the TCF to qualified hospitals, subject to the provisions in this section and subject to legislative action.
(3) To qualify for supplemental distributions from the TCF, a hospital must:
(a) Be designated or recognized by the department of health (DOH) as an approved Level 1, Level 2, or Level 3 adult or pediatric trauma service center;
(b) Meet the provider requirements in this section and other applicable WAC;
(c) Meet the billing requirements in this section and other applicable WAC;
(d) Submit all information the department requires to ensure services are being provided; and
(e) Comply with DOH's Trauma Registry reporting requirements.
(4) Supplemental distributions from the TCF are:
(a) Allocated into five fixed payment pools of equal
amounts. Timing of payments is described in subsection (5) of
this section. Distributions from the payment pools to the
individual hospitals are determined by first summing each
eligible hospital's qualifying payments since the beginning of
the service year and expressing this amount as a percentage of
total payments to all eligible hospitals for qualifying
services provided during the service year to date. Each
hospital's qualifying payment percentage for the service
year-to-date is multiplied by the available amount ((
current period pool)) for the service year-to-date, and then
the department subtracts what has been allocated to each
hospital for the service year-to-date to determine the portion
of the current quarterly payment pool to be paid to each
qualifying hospital. This method for determining supplemental
distributions to hospitals applies to TCF allotments beginning
with state fiscal year (SFY) 2008. This method supersedes and
preempts the method adopted in rule and effective August 1,
2007. Eligible hospitals and qualifying payments are
described in (i) through (iii) of this subsection:
(i) Qualifying payments are the department's payments to Level 1, Level 2, and Level 3 trauma service centers for qualified Medicaid trauma cases since the beginning of the service year. The department determines the countable payment for trauma care provided to Medicaid clients based on date of service, not date of payment;
(ii) The department's payments to Level 1, Level 2, and Level 3 hospitals for trauma cases transferred in since the beginning of the service year. A Level 1, Level 2, or Level 3 hospital that receives a transferred trauma case from any lower level hospital is eligible for the enhanced payment, regardless of the client's injury severity score (ISS). An ISS is a summary rating system for traumatic anatomic injuries; and
(iii) The department's payments to Level 2 and Level 3 hospitals for qualified trauma cases (those that meet or exceed the ISS criteria in subsection (4)(b) of this section) that these hospitals transferred to a higher level designated trauma service center since the beginning of the service year.
(b) Paid only for a Medicaid trauma case that meets:
(i) The ISS of thirteen or greater for an adult trauma patient (a client age fifteen or older);
(ii) The ISS of nine or greater for a pediatric trauma patient (a client younger than age fifteen); or
(iii) The conditions of subsection (4)(c).
(c) Made to hospitals, as follows, for a trauma case that is transferred:
(i) A hospital that receives the transferred trauma case qualifies for payment regardless of the ISS if the hospital is designated or recognized by DOH as an approved Level 1, Level 2, or Level 3 adult or pediatric trauma service center;
(ii) A hospital that transfers the trauma case qualifies for payment only if:
(A) It is designated or recognized by DOH as an approved Level 2 or Level 3 adult or pediatric trauma service center; and
(B) The ISS requirements in (b)(i) or (b)(ii) of this subsection are met.
(iii) A hospital that DOH designates or recognizes as an approved Level 4 or Level 5 trauma service center does not qualify for supplemental distributions for trauma cases that are transferred in or transferred out, even when the transferred cases meet the ISS criteria in subsection (4)(b) of this section.
(d) Not funded by disproportionate share hospital (DSH) funds; and
(e) Not distributed by the department to:
(i) Trauma service centers designated or recognized as Level 4 or Level 5;
(ii) Critical access hospitals (CAHs), except when the
CAH is also a Level 3 trauma service center. Beginning with
qualifying trauma services provided in ((
state fiscal year
())SFY(( ))) 2007, the department allows a hospital with this
dual status to receive distributions from the TCF; or
(iii) Any hospital for follow-up surgical services related to the qualifying trauma incident but provided to the client after the client has been discharged for the initial qualifying injury.
(5) Distributions for an SFY are divided into five "quarters" and paid as follows:
(a) Each quarterly distribution paid by the department from the TCF totals twenty percent of the amount designated by the department for that SFY;
(b) The first quarterly supplemental distribution from the TCF is made six months after the SFY begins;
(c) Subsequent quarterly payments are made approximately every four months after the first quarterly payment is made, except as described in subsection (d);
(d) The "fifth quarter" final distribution from the TCF for the same SFY is:
(i) Made one year after the end of the SFY;
(ii) Based on the SFY that the TCF designated amount relates to; and
(iii) Distributed based on each eligible hospital's percentage of the total payments made by the department to all designated trauma service centers for qualified trauma cases during the relevant fiscal year.
(6) For purposes of the supplemental distributions from the TCF, all of the following apply:
(a) The department may consider a request for a claim adjustment submitted by a provider only if the request is received by the department within one year from the date of the initial trauma service;
(b) The department does not allow any carryover of liabilities for a supplemental distribution from the TCF beyond three hundred sixty-five calendar days from the date of discharge (inpatient) or date of service (outpatient). The deadline for making adjustments to a trauma claim is the same as the deadline for submitting the initial claim to the department as specified in WAC 388-502-0150(3). WAC 388-502-0150(7) does not apply to TCF claims;
(c) All claims and claim adjustments are subject to federal and state audit and review requirements; and
(d) The total amount of supplemental distributions from the TCF disbursed to eligible hospitals by the department in any biennium cannot exceed the amount appropriated by the legislature for that biennium. The department has the authority to take whatever actions necessary to ensure the department stays within the TCF appropriation.
[Statutory Authority: RCW 74.08.090, 74.09.500. 07-14-090, § 388-550-5450, filed 6/29/07, effective 8/1/07; 06-08-046, § 388-550-5450, filed 3/30/06, effective 4/30/06; 04-19-113, § 388-550-5450, filed 9/21/04, effective 10/22/04.]